What is the most likely treatment approach for a patient with a perforated duodenal ulcer and free air in the abdomen?

Management of Perforated Duodenal Ulcer

Primary repair with omentopexy is the most appropriate treatment approach for a patient with a perforated duodenal ulcer and free air in the abdomen.

Initial Assessment and Management

• Patients presenting with rigid abdominal pain and free air on direct graphy require immediate surgical intervention, as every hour of delay from admission to surgery is associated with a 2.4% decreased probability of survival 1
• Hemodynamic stabilization should be initiated promptly while preparing for surgery 2
• Operative treatment is strongly recommended for patients with significant pneumoperitoneum, extraluminal contrast extravasation, or signs of peritonitis 1

Surgical Approach Selection

• For hemodynamically stable patients with perforated duodenal ulcer, a laparoscopic approach is suggested 1
• Open approach should be considered for patients with hemodynamic instability, severe sepsis, or when laparoscopic expertise is unavailable 1
• The effects of increased intra-abdominal pressure and hypercarbia during laparoscopy preclude this approach in hemodynamically unstable patients 1

Primary Repair with Omentopexy

• For duodenal ulcers smaller than 2 cm, primary repair with omentopexy is the standard treatment 1, 2
• The procedure involves suturing the perforation and reinforcing it with an omental patch 3
• Simple "one-stitch" suture with omental patch technique has been shown to be safe and effective with acceptable morbidity rates 3
• Laparoscopic omental patch repair offers advantages including decreased postoperative pain and faster recovery when performed by experienced surgeons 4

Management Based on Perforation Size

• For small perforations (<1 cm), primary suture with omental patch reinforcement is recommended 2
• For perforations between 1-2 cm, primary repair with omentopexy remains the standard approach 1
• For large perforations (≥2 cm), more complex procedures may be required based on the location of the perforation 1

Alternative Procedures for Complex Cases

• For large duodenal perforations (>2 cm) or those close to the ampulla of Vater, more complex procedures may be necessary 1
• Several different procedures such as jejunal serosal patch, Roux en-Y duodenojejunostomy, or pyloric exclusion may be considered for large defects when primary repair is not feasible 1
• In cases of severe septic shock with hemodynamic instability, damage control surgery may be appropriate 1

Special Considerations

• The proximity of the perforation to the common bile duct and ampulla of Vater must be thoroughly investigated 1, 5
• Intraoperative cholangiography may be necessary to verify common bile duct anatomy in complex cases 1
• Elevated amylase levels may indicate proximity of the perforation to the ampulla of Vater, requiring special attention during repair 5

Postoperative Care

• Proton pump inhibitor therapy should be continued postoperatively 6
• Evaluation for Helicobacter pylori infection should be conducted following recovery 7
• Long-term PPI therapy is important as patients who stop taking PPIs after approximately 22 months have increased risk of recurrence 6

Common Pitfalls to Avoid

• Attempting complex resections in hemodynamically unstable patients 2
• Underestimating the severity of peritonitis, which may require a more aggressive surgical approach 2
• Failure to continue PPI therapy postoperatively, as omental patching does not correct the underlying disease process 6